37
Compiled by: Dr Ambika Bhandari MDS 1 st yr DELTOPECTORAL FLAP

Deltopectoral Flap

Embed Size (px)

Citation preview

Page 1: Deltopectoral Flap

Compiled by:

Dr Ambika Bhandari

MDS 1st yr

DELTOPECTORAL FLAP

Page 2: Deltopectoral Flap

Introduction HistoryAnatomyIndicationsTechniqueComplicationsAdvantages Disadvantages

CONTENTS

Page 3: Deltopectoral Flap

The current treatment objective of head and neck cancer patient is the removal of the tumor and to preserve and restore preoperative activity and quality of life.

However during the excision exposure of vital structures such as the brain, eye or major neurovascular structures is observed which cannot be left as such.

INTRODUCTION

Page 4: Deltopectoral Flap

Hence, reconstruction is needed, may it be of the most basic type as the direct suturing.

The choice of the type of reconstruction is based on various aspects such as the size, the site and suitability

Page 5: Deltopectoral Flap

Surgical options for head and neck reconstruction have been described schematically as a ladder:

Direct closure Skin grafting Local flapsDistant flaps Cutaneous and myocutaneous pedicled flapsMicrovascular free flaps

Page 6: Deltopectoral Flap

A skin flap is basically a tongue of tissue consisting an entire thickness of skin and variable amount of the underlying subcutaneous tissue.

This flap is used to reconstruct a primary defect leaving behind a secondary defect which may be closed by direct suturing or a skin graft.

If the flap is raised from the adjoining areas to the primary defect then it is called as a local flap.

Page 7: Deltopectoral Flap

If a flap is raised which involves movement of the tissue at a distance from the primary defect then it is called a distant flap.

Page 8: Deltopectoral Flap

The deltopectoral flap was the workhorse for intraoral, cheek and neck reconstruction in the 1960s and 1970s.

It was first described by BAKAMJIAN in 1965.It was the first axial pattern skin flap derived

from an outside area for direct reconstruction of head and neck region.

HISTORY

Page 9: Deltopectoral Flap

The skin of the thorax is supplied by a combination of direct cutaneous vessels and musculocutaneous perforators which reach the skin primarily via the intercostal muscles, pectoralis major and other muscles.

The deltopectoral flap is an axial pattern flap i.e. it is constructed around an arteriovenous system and designed on the anterior superior chest wall.

FLAP DESIGN

Page 10: Deltopectoral Flap
Page 11: Deltopectoral Flap

The deltopectoral flap is based on the first, second, and third perforators (sometimes the fourth also) of the internal mammary artery and associated veins.

The distal part of the flap is not considered as axial pattern as the vascular system of the flap ends at the groove separating the deltoid from the pectoralis major muscle.

This flap is based on the midline from which it passes horizontally towards the shoulder.

Page 12: Deltopectoral Flap
Page 13: Deltopectoral Flap

The base of the flap is located at 2 cm from the sternal edge, where the perforators pierce in the intercoastal space.

The plane of raising the flap is between the deep fascia and the pectoralis major muscle.

Page 14: Deltopectoral Flap

The secondary defect after the flap elevation shows exposed pectoralis major muscle which may be closed by either direct closure or by placing a skin graft as it is an ideal site for the same .

The skin graft may be placed temporary in cases where the bridge segment of the deltopectoral flap is returned to its original site after the division of the flap.

Laterally it extends as far as the mid lateral line of the deltoid muscle.

Page 15: Deltopectoral Flap
Page 16: Deltopectoral Flap

The deltopectoral flap for planning can be viewed as a very large transposed flap with a pivot point from which the measurements are made.

The geometry of this flap is typical due to the presence of slack skin over the anterior axillary fold.

broad shoulders and short neck are better for optimal flap.

PLANNING OF FLAP

Page 17: Deltopectoral Flap

The lower border of the flap is longer than the upper border so any tension during the placement of the flap is transferred to the short upper border, in order to avoid this, the measurements are taken from the medial point of the upper border. ( McGregor & Jackson 1970)

Page 18: Deltopectoral Flap
Page 19: Deltopectoral Flap

Patient is draped and painted, placed in supine position.

Arm may be adducted or abducted as per the surgeons convenience.

Land marks-sternal edgeinfraclavicular line deltopectoral groove nipple.

Flap is marked diagnally upward with its base over second third and fourth coastal cartilages.

TECHNIQUE

Page 20: Deltopectoral Flap
Page 21: Deltopectoral Flap

Upper incision starts 2cm distal to the sternal edge, follows the infraclavicular line beyond the deltopectoral groove onto the anterior shoulder.

The lower incision parallels the upper incision extending to the line of the anterior axillary fold above the fifth thoracic intercoastal space ( a few cms above the undisplaced nipple)

The distal incision is placed through the skin and subcutaneous tisssues including fascia over the deltoid muscle.

Page 22: Deltopectoral Flap
Page 23: Deltopectoral Flap

Elevation proceeds from distal to proximal.Fascia overlying the muscle is included in the

flap.The dissection then proceeds rapidly through

a relatively bloodless plane across the deltoid, the deltopectoral groove and onto the pectoralis major muscle.

The dissection is continued until the perforators are seen emerging through the pectoralis major muscles.

Page 24: Deltopectoral Flap
Page 25: Deltopectoral Flap

Rotational transfer- can resurface the entire adjacent skin of the neck in cancer cases where skin of neck is involved.

Subcutaneous transfer – this is done subcutaneously with the flap pedicle deepithilialized leaving the distal portion like an island flap. Such a flap is used for covering high cervical defects.

Bridging over the neck- the pedicle is tubed and the distal part is used for reconstruction.

Page 26: Deltopectoral Flap
Page 27: Deltopectoral Flap
Page 28: Deltopectoral Flap
Page 29: Deltopectoral Flap

For intraoral reconstruction the tubed flap is approximated to the mucosa and muscle edges of the defect.

Then at the second stage when the tube is divided and the proximal divided portions of the flap are inset, it is done 2 to 3 weeks after the initial procedure.

Page 30: Deltopectoral Flap

Infection of the flap.Necrosis may have many reasons as tension

on the flap, trauma to the vessels during raising or due to faulty flap design i.e. straight line extensions to the shoulder or ‘L’ shaped extension oh to the upper arm.

Extensions of this flap are not recommended.Late sequel as fistula and strictures.

COMPLICATIONS

Page 31: Deltopectoral Flap

Reconstruction after head and neck tumor excision.

pharyngo cutaneous and orocutaneos fistula closure.

Reconstruction of large cutaneous cervical defects.

 postburn head and neck reconstruction perioral reconstruction after ballistic traumaHypo pharyngeal reconstruction.

INDICATIONS

Page 32: Deltopectoral Flap

Prior chest wall surgery or injury eg radical mastectomy, pacemaker

Prior cardiac surgery with use of internal thoracic artery for by pass.

Not much reliable in post radiation patients.

CONTRAINDICATIONS

Page 33: Deltopectoral Flap

The deltopectoral flap does not require prior delay of any kind this being the major advantage.

The flap design can be modified in the area by choosing only one perforator vessel system generally second one is used.

Less donor site morbidity is seen.Accurately replaces the components of the

recipient site.

ADVANTAGES

Page 34: Deltopectoral Flap
Page 35: Deltopectoral Flap
Page 36: Deltopectoral Flap

Limited reach is the only disadvantage of this flap.

Patients with anemia, advanced atherosclerosis, diabetes etc may experience flap faliure due to compromised blood supply. In such cases a delay of 7 to 10 days is preferrable.

DISADVANTAGES

Page 37: Deltopectoral Flap

THANK YOU.